Publications by authors named "Elizabeth Waring"

9 Publications

  • Page 1 of 1

Assessment of Written Feedback for Emergency Medicine Residents.

South Med J 2020 Sep;113(9):451-456

From the Department of Emergency Medicine, Staten Island University Hospital, Northwell Health, Staten Island, New York.

Objectives: An essential component of resident growth is a learning environment with high-quality feedback. Criteria have been developed for characterizing and assessing written feedback quality in internal medicine residents by Jackson et al. Our primary goal was to describe feedback characteristics and assess the quality of written feedback for emergency medicine (EM) residents. Our secondary goals were to evaluate the relation between feedback quality and objective outcome measures.

Methods: This retrospective study was conducted between July 1, 2016 and July 1, 2018. EM residents with an Accreditation Council for Graduate Medical Education composite score (ACS), an in-service score, and written evaluations completed by an attending physician or EM resident in each of the 2 years of the study period were included.

Results: Overall, most of the evaluations contained 1 (21%), 2 (23%), or 3 (17%) feedback items. Feedback tended to be positive (82%) and the feedback quality of the evaluations was more likely to be high (44%). There was an association between feedback quality and ACS change ( < 0.0001), but not in-service score change ( = 0.63). Resident evaluations were more likely than attending evaluations to correlate with ACS change ( < 0.00001).

Conclusions: The written evaluations contained few individual feedback items. Evaluations generally focused on the feedback characteristics of professionalism and interpersonal communication. The general feedback quality of evaluations tended to be high and correlated with an increase in ACSs.
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http://dx.doi.org/10.14423/SMJ.0000000000001142DOI Listing
September 2020

Evaluation of a community-based dental screening program prior to radiotherapy for head and neck cancer: a single-center experience.

Support Care Cancer 2019 Sep 7;27(9):3331-3336. Epub 2019 Jan 7.

Division of Oral Medicine and Dentistry, Brigham and Women's Hospital, Boston, MA, USA.

Purpose: Oral toxicities following radiation therapy (RT) for head and neck (HN) cancer can be profound and are associated with poor health outcomes. The Division of Oral Medicine and Dentistry at Brigham and Women's Hospital and Dana-Farber Cancer Institute therefore implemented a dental evaluation program designed for community-based (CB) dentists to evaluate and treat patients scheduled for HN RT. The aim of this retrospective single-center cohort study was to assess the compliance of CB dentists with this pre-RT dental evaluation program.

Methods: A retrospective analysis of dental evaluations completed by CB dentists from December 2013 to December 2015 was performed. Descriptive statistics were used to determine compliance.

Results: A total of 186 dental evaluations were received. Compliance with completion of dental treatment was as follows: scaling and prophylaxis: 94.5% (172/182); dental restorations: 78.7% (48/61); endodontic therapy: 76.9% (10/13); and dental extractions: 76.9% (30/39). Compliance of CB dentists with all requested components of the pre-RT evaluation and treatment was 77.4% (144/186). The median distance traveled by patients to the CB dentist and to the hospital was 5.2 miles (range 0.03-66.0) and 46.5 miles (range 0.8-1457; p < 0.01), respectively.

Conclusion: In this study, the majority of patients completed their necessary dental treatment in a timely manner by their CB dentist in collaboration with an oral medicine specialist. Given the high compliance of CB dentists, this program could serve as a model for other cancer centers to optimize oral and dental health prior to RT.
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http://dx.doi.org/10.1007/s00520-018-4626-yDOI Listing
September 2019

Intravenous Thrombolysis at 3.5 Hours From Onset of Pediatric Acute Ischemic Stroke.

Pediatr Emerg Care 2020 Jan;36(1):e4-e7

From the Seton Dell Medical School Stroke Institute, Austin, TX.

Acute thrombolysis has a proven benefit for adults presenting with acute ischemic stroke, but data within the pediatric population are extremely limited. We report the case of a 14-year-old girl who presented with right-sided weakness and ataxia, loss of sensation, and altered mental status. Magnetic resonance imaging with diffusion-weighted imaging showed an acute lesion in the distribution of the left posterior cerebral artery, and magnetic resonance angiogram demonstrated occlusion of the third branch of the left posterior cerebral artery. With parental consent, clinicians decided to infuse an adult dose of weight-adjusted intravenous alteplase at 3.5 hours from onset of symptoms, with subsequent improvement in National Institutes of Health Stroke Scale score from 11 to 3. Computed tomography angiogram at 24 hours showed recanalization of the occluded vessel with no evidence of intracranial hemorrhage. Stroke Scale score at discharge was 3, with modified Rankin Scale scores at discharge of 1 and at 90 days of 0. This case highlights the importance of magnetic resonance imaging in diagnosing pediatric acute ischemic stroke and suggests consideration of thrombolysis in select confirmed pediatric stroke cases. However, a rigorous evidence base is lacking, and clinical trials have not been successful in recruiting patients.
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http://dx.doi.org/10.1097/PEC.0000000000001419DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6077109PMC
January 2020

Oral Manifestations of Immunodeficiencies and Transplantation Medicine.

Atlas Oral Maxillofac Surg Clin North Am 2017 Sep;25(2):105-111

Division of Oral Medicine and Dentistry, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02215, USA.

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http://dx.doi.org/10.1016/j.cxom.2017.04.003DOI Listing
September 2017

High growth temperatures and high soil nitrogen do not alter differences in CO assimilation between invasive Phalaris arundinacea (reed canarygrass) and Carex stricta (tussock sedge).

Am J Bot 2017 Jul;104(7):999-1007

Department of Biological Sciences, Texas Tech University, Lubbock, Texas 79409 USA.

Premise Of The Study: Global change in temperature and soil nitrogen availability could affect plant community composition, potentially giving an advantage to invasive species compared to native species. We addressed how high temperatures affected CO assimilation parameters for invasive Phalaris arundinacea and a sedge, Carex stricta, it displaces, in natural and controlled environments.

Methods: Photosynthetic parameters were measured in a wetland in Indiana, USA during the abnormally warm year of 2012. In a growth chamber, photosynthetic parameters were measured on the plants grown under three levels of nitrogen and exposed to optimum temperatures followed by 2012-like summer conditions and then hot temperatures with an autumn-like photoperiod.

Key Results: In the wetland, C. stricta exhibited signs of midsummer leaf senescence, whereas P. arundinacea maintained CO assimilation at ambient pCO (A ) through mid-October. In the chamber, 2012-like conditions reduced A for both species through reductions in maximum carboxylation (V ) and electron transport (J ) without further change during subsequent hot, autumn-like conditions, whereas the quantum efficiency of carbon assimilation (qe) declined throughout the experiment. However, P. arundinacea had higher values of A , J , and qe than C. stricta. A general, the positive effect of increasing nitrogen availability occurred for photosynthetic processes for both species in hot conditions.

Conclusions: Our data suggest that C. stricta is more susceptible to excessive light stress than P. arundinacea during hot, sunny periods, leading to leaf senescence. Field confirmation of this idea is needed, but frequent heat waves should favor P. arundinacea over C. stricta with or without eutrophication.
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http://dx.doi.org/10.3732/ajb.1600339DOI Listing
July 2017

Intravenous Tissue Plasminogen Activator for Wake-Up Stroke: A Propensity Score-Matched Analysis.

J Stroke Cerebrovasc Dis 2016 Nov 28;25(11):2603-2609. Epub 2016 Jul 28.

Stroke Program, Department of Neurology, Tulane University School of Medicine, New Orleans, Louisiana. Electronic address:

Goal: To evaluate the safety and efficacy of intravenous (IV) tissue plasminogen activator (tPA) in the treatment of wake-up stroke (WUS) using propensity score (PS) analysis.

Materials And Methods: Consecutive acute ischemic stroke patients meeting inclusion criteria were retrospectively identified from our stroke registry between July 2008 and May 2014, and classified as stroke onset less than or equal to 4.5 hours treated with tPA (control; n = 369), tPA-treated WUS (n = 46), or nontreated WUS (n = 154). The primary outcome of interest for safety was symptomatic intracerebral hemorrhage (sICH), defined as parenchymal hemorrhage associated with a greater than or equal to 4-point increase in National Institutes of Health Stroke Scale (NIHSS) score. Multivariate logistic regression with adjustment for confounders and PS for receiving IV tPA assessed outcomes, along with PS-matched average treatment effect on the treated (ATT).

Findings: No significant difference was found in rates of sICH between tPA-treated WUS, nontreated WUS, and controls (2.2%, .7%, and 3%, respectively), or in the odds of sICH between tPA-treated WUS and controls (OR = .53, 95% CI = .06-4.60, P = .568). Among WUS patients, tPA treatment was significantly associated with higher odds of good functional outcome in fully adjusted analyses (OR = 7.22, 95% CI = 2.28-22.88, P = .001). The ATT of tPA for WUS patients demonstrated a significantly greater decrease in NIHSS score at discharge when compared to nontreated WUS patients (-4.32 versus -.34, P = .032).

Conclusions: Comparable rates of sICH between treated WUS and stroke onset less than or equal to 4.5 hours treated with tPA suggest that tPA may be safely used to treat WUS. Superior outcomes for tPA-treated versus nontreated WUS subjects may suggest clinical efficacy of the treatment.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2016.06.044DOI Listing
November 2016

Plasticity of nitrogen allocation in the leaves of the invasive wetland grass, Phalaris arundinacea and co-occurring Carex species determines the photosynthetic sensitivity to nitrogen availability.

J Plant Physiol 2015 Apr 25;177:20-29. Epub 2015 Jan 25.

Department of Biological Sciences, Texas Tech University, Flint and Main Streets, Lubbock, TX 79409-3131, USA.

Phalaris arundinacea displaces the slower-growing, native sedge, Carex stricta, where nitrogen availability is high. Our aim was to address whether morphological and physiological traits associated with carbon gain for P. arundinacea and C. stricta responded to nitrogen supply differently and if the species exhibited different degrees of plasticity in these traits. The plants were grown in gravel and provided modified Hoagland's solution containing four nitrogen concentrations from 0.15 to 15 mM for 6 to 7 weeks. Supplied nitrogen affected the leaf nitrogen content to the same degree for both species. Increasing supplied nitrogen strongly increased CO2 assimilation (A), photosynthetic nitrogen use efficiency (PNUE), and respiration for P. arundinacea but had only a small effect on these parameters for C. stricta. Relative to growth at 15 mM nitrogen, growth at 0.15 mM for young leaves decreased carboxylation capacity and efficiency and the capacity for electron transport for P. arundinacea and a larger, stouter Carex species, Carex lacustris, by 53 to 70% but only 20 to 24% for C. stricta. Leaf nitrogen decreased approximately 50% for all species, but vacuolar nitrate did not decrease for P. arundinacea and C. stricta, suggesting that it does not serve as a nitrogen reserve for use during nitrogen deprivation in these species. After 4 months of nitrogen deprivation, P. arundinacea doubled A in 12 days after being supplied 15 mM nitrogen, whereas A for C. stricta increased only 22%. We propose that one factor linking P. arundinacea abundance to nitrogen availability involves this species' plastic response of carbon gain to nitrogen supply. C. stricta appears to be adapted to tolerate low nitrogen availability but cannot respond as rapidly and extensively as P. arundinacea when nitrogen supply is high.
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http://dx.doi.org/10.1016/j.jplph.2015.01.008DOI Listing
April 2015

Plant dieback under exceptional drought driven by elevation, not by plant traits, in Big Bend National Park, Texas, USA.

PeerJ 2014 15;2:e477. Epub 2014 Jul 15.

Texas Tech University, Department of Biological Sciences , Lubbock, TX , USA.

In 2011, Big Bend National Park, Texas, USA, experienced the most severe single year drought in its recorded history, resulting in significant plant mortality. We used this event to test how perennial plant response to drought varied across elevation, plant growth form and leaf traits. In October 2010 and October 2011, we measured plant cover by species at six evenly-spaced elevations ranging from Chihuahuan desert (666 m) to oak forest in the Chisos mountains (1,920 m). We asked the following questions: what was the relationship between elevation and stem dieback and did susceptibility to drought differ among functional groups or by leaf traits? In 2010, pre-drought, we measured leaf mass per area (LMA) on each species. In 2011, the percent of canopy dieback for each individual was visually estimated. Living canopy cover decreased significantly after the drought of 2011 and dieback decreased with elevation. There was no relationship between LMA and dieback within elevations. The negative relationship between proportional dieback and elevation was consistent in shrub and succulent species, which were the most common growth forms across elevations, indicating that dieback was largely driven by elevation and not by species traits. Growth form turnover did not influence canopy dieback; differences in canopy cover and proportional dieback among elevations were driven primarily by differences in drought severity. These results indicate that the 2011 drought in Big Bend National Park had a large effect on communities at all elevations with average dieback for all woody plants ranging from 8% dieback at the highest elevation to 83% dieback at lowest elevations.
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http://dx.doi.org/10.7717/peerj.477DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4106195PMC
August 2014

Antecedent hypoglycemia impairs autonomic cardiovascular function: implications for rigorous glycemic control.

Diabetes 2009 Feb 3;58(2):360-6. Epub 2008 Dec 3.

Division of Endocrinology, Diabetes, and Hypertension, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.

Objective: Glycemic control decreases the incidence and progression of diabetic complications but increases the incidence of hypoglycemia. Hypoglycemia can impair hormonal and autonomic responses to subsequent hypoglycemia. Intensive glycemic control may increase mortality in individuals with type 2 diabetes at high risk for cardiovascular complications. We tested the hypothesis that prior exposure to hypoglycemia leads to impaired cardiovascular autonomic function.

Research Design And Methods: Twenty healthy subjects (age 28 +/- 2 years; 10 men) participated in two 3-day inpatient visits, separated by 1-3 months. Autonomic testing was performed on days 1 and 3 to measure sympathetic, parasympathetic, and baroreflex function. A 2-h hyperinsulinemic [hypoglycemic (2.8 mmol/l) or euglycemic (5.0 mmol/l)] clamp was performed in the morning and in the afternoon of day 2.

Results: Comparison of the day 3 autonomic measurements demonstrated that antecedent hypoglycemia leads to 1) reduced baroreflex sensitivity (16.7 +/- 1.8 vs. 13.8 +/- 1.4 ms/mmHg, P = 0.03); 2) decreased muscle sympathetic nerve activity response to transient nitroprusside-induced hypotension (53.3 +/- 3.7 vs. 40.1 +/- 2.7 bursts/min, P < 0.01); and 3) reduced (P < 0.001) plasma norepinephrine response to lower body negative pressure (3.0 +/- 0.3 vs. 2.0 +/- 0.2 nmol/l at -40 mmHg).

Conclusions: Baroreflex sensitivity and the sympathetic response to hypotensive stress are attenuated after antecedent hypoglycemia. Because impaired autonomic function, including decreased cardiac vagal baroreflex sensitivity, may contribute directly to mortality in diabetes and cardiovascular disease, our findings raise new concerns regarding the consequences of hypoglycemia.
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http://dx.doi.org/10.2337/db08-1153DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2628609PMC
February 2009