bluuebunny/crossref_metadata_2025 huggingface dataset:
Development of the Nursing Quality Improvement in Practice Tool
Authors: Tschannen Dana , Alexander Catherine , Tovar Elizabeth G. , Ghosh Bidisha , Zellefrow Cindy , Milner Kerry A.
Published: January 2020

Background:

Frontline nurse engagement in quality improvement (QI) improves nurse-sensitive outcomes; yet research suggests frontline nurses are not engaging in QI.

Purpose:

The purpose of this study was to develop, refine, and psychometrically evaluate the Nursing Quality Improvement in Practice (N-QuIP) tool to measure nurses' competency, engagement, and barriers/facilitators to QI engagement.

Methods:

Item development was guided by an expert panel and literature review. Factor analysis and reliability indices were assessed through 681 surveys completed by nurses at one medical center.

Results:

Cronbach α coefficients were 0.97 (Skill Scale) and 0.90 (Attitude Scale). Kuder-Richardson Formula 20 (KR-20) for knowledge was 0.36. Exploratory factor analysis identified 4 (Skill) and 3 (Attitude) subscales respectively, aligning well with QI competencies.

Conclusions:

Preliminary data suggest that the N-QuIP is a valid and reliable tool for assessing nurse QI competence and engagement. Understanding current knowledge, skills, and attitudes and identified barriers/facilitators can help the development of strategies aimed at increasing QI engagement.
Evaluating the Humpty Dumpty Fall Scale
Authors: Gonzalez Jackie , Hill-Rodriguez Deborah , Hernandez Laura M. , Cordo Jennifer A. , Esteves Jenny , Wang Weize , Salyakina Daria , Sarik Danielle Altares
Published: January 2020

Background:

The Humpty Dumpty Falls Prevention Program was developed to address an unmet need to identify pediatric patients at risk of a fall event.

Purpose:

The aim of this study was to evaluate the performance of the Humpty Dumpty Fall Scale-Inpatient (HDFS) across a diverse, international pediatric population. In addition, the characteristics of patients who experienced a fall were analyzed.

Methods:

A retrospective, cross-sectional design was used to assess fall risk across 16 hospitals and 2238 pediatric patients. Multiple and simple logistic regressions were performed to evaluate association of individual scale items and total score with falls during hospitalization. Reliability, sensitivity, and specificity of the HDFS were also assessed.

Results:

Several of the HDFS items were significantly associated with the risk of falls in the pediatric population, but specificity of the tool is a concern to consider for future tool enhancement.

Conclusions:

Characteristics for further refinement of the HDFS were identified.
Improving Throughput for Patients Admitted From the Emergency Department
Authors: Wolak Eric , Jones Cheryl , Leeman Jennifer , Madigan Catherine
Published: January 2020

Background:

Inefficient emergency department to inpatient handoff processes can contribute to delayed care.

Local Problem:

The average emergency department length of stay for admitted patients and admission wait times at this institution were well above national averages, and a standard handoff process was lacking.

Methods:

Lean methodology was used to evaluate flow and identify opportunities for improvement.

Interventions:

Two tools were developed to standardize handoff.

Results:

Emergency department length of stay and admission wait times were not significantly improved following intervention implementation. However, patient transfer time decreased significantly (P < .01, F = 29.02) from 30.5 minutes (SD = 18.2) to 21.7 minutes (SD = 7.4). The length of time to give/receive report also decreased significantly (P = .04, F = 2.2) from 3.8 (SD = 1.6) minutes to 2.8 (SD = 1.2) minutes.

Conclusions:

Although length of stay and admission wait times did not decline significantly, implementation of standard work and tools can potentially improve patient flow.
Outcomes of a Nurse-Led Difficult Urinary Catheter Team in an Academic Medical Center
Authors: Price David , McKeon Leslie
Published: January 2020

Background:

Catheter insertion for complex patients by inexperienced nurses can lead to avoidable iatrogenic urethral injury and catheter-associated urinary tract infection (CAUTI).

Purpose:

The study aim was to evaluate a comprehensive nurse-led difficult urinary catheterization (DUC) Program to reduce patient CAUTIs.

Methods:

A retrospective cohort study design was used to evaluate the DUC Program's effectiveness during 2013 to 2017. Measures included RN DUC consultations, protocol adherence, patient CAUTIs, and urology consults.

Results:

The RN DUC team consulted 435 patients with a 92% insertion success rate. The DUC protocol adherence was 66.1%. Patient CAUTIs decreased from baseline (169) to year 4 (24) (odds ratio: 0.1889, 95% confidence interval = 0.1231-0.2898, P < .001). Urology consults decreased from baseline (40) to year 3 (21), however, increased in year 4 (80) when a urology residency program was started.

Conclusion:

This comprehensive program was effective in improving catheter insertion technique, eliminating urology consults, and reducing CAUTIs when combined with organizational prevention measures.
Comparison of a Nurse-Nurse Handoff Mnemonic With Real-World Handoffs
Authors: O'Rourke Jennifer , Lopez Karen Dunn , Riesenberg Lee Ann , Abraham Joanna
Published: January 2020

Background:

Communication failures, including clinical handoff or clinical handover errors, contribute to 80% of all serious preventable adverse events each year. The N-PAS, N = Nurse, P = Patient Summary, A = Action Plan, and S = Synthesis, is a flexible standardized clinical handoff tool for nurses.

Purpose:

The purpose of this study was to determine the proportion of N-PAS core components present in real-world patient handoffs.

Methods:

A mixed-methods design was used to analyze secondary data. Patient handoffs (n = 138) were transcribed into statements and then independently coded by 2 research assistants.

Results:

Of all handoff statements, 63.2% were coded as Patient Summary and 13.6% were coded as Action Plan, whereas Synthesis was not coded in any handoffs. Three new Patient Summary elements and 1 new Action Plan element were identified.

Conclusion:

Patient Summary and Action Plan are critical data reported during clinical handoff. A handoff synthesis is a critical step to include in handoff training.
Predischarge Provider Visits as a Method of Improving Transitional Care Clinic Visit Rates
Authors: James Tess C. , Corbett Cynthia F. , Jones Katherine , Moore-Gibbs Ashley
Published: January 2020

Background:

Transitional care interventions have been associated with reduced 30-day patient readmission, better quality of health care, and lower emergency department visits and health care costs.

Local Problem:

Transition Services at a major quaternary care center was underutilized by patients who were referred to the program.

Methods:

A pre-/postimplementation evaluation design was used to evaluate a quality improvement intervention.

Intervention:

A face-to-face meeting between eligible patients and a Transition Services provider prior to patients being discharged from the hospital was evaluated as a process improvement intervention. The primary outcome was initial appointment attendance at the Transition Services clinic following hospital discharge.

Results:

There was no statistically significant difference (P = .59) in patients' initial appointment attendance at Transition Services between the preintervention (48.1%) and intervention phases (54.8%).

Conclusion:

Provider engagement during hospitalization did not increase initial appointment attendance at Transition Services. Other strategies to improve Transition Services attendance rates are needed.
Implementation of Fall Preventions Over the Past 15 Years
Authors: Taylor Beth , Tymkew Heidi , Vyers Kara , Taylor Madeline , Roney Wilhelmina , Costantinou Eileen
Published: January 2020

Background:

Hospital fall rates have changed minimally with preventive measures; however, the effect on injury rate is unclear.

Purpose:

The purpose was to determine whether fall-related injuries have changed over time.

Methods:

A retrospective comparison was done of 1134 adult inpatient falls in 2017 to 1235 falls in 2001-2002 for injury and fall circumstances. Separate comparisons were made of patient characteristics by service line for 2017.

Results:

Severe fall injuries declined from 6% to 2.4%. Elimination issues remained the most common circumstance (38.9% and 42%). In 2017, malnutrition (31.6%), low function (61.4%), fall history (26.3%), and use of high-risk medications (83.2%) were common in patients who fell. Predictors of falls with injury by patient population were as follows: surgery—male gender (P = .01), low function (P = .006), elimination issues (P = .04); oncology—low function (P = .04); and neurology—low function (P = .02).

Conclusions:

Severe fall-related injuries have decreased in the past 15 years. The most common circumstance for falls remains elimination issues.
Non-Neoplastic Mediastinal Cysts
Authors: Syred Katherine , Weissferdt Annikka
Published: January 2020

Primary mediastinal cysts are infrequent lesions that can arise from a variety of mediastinal organs or structures. Most of these are congenital in origin and incidental findings during investigations for unrelated conditions. Histologically, the cysts may be composed of various tissues, including bronchogenic, pericardial, thymic, enteric, Müllerian, lymphatic, and parathyroid types. Mediastinal cysts typically demonstrate a benign clinical course and patients are cured after complete surgical resection. In this review, the embryogenesis, clinical, radiologic, and pathologic characteristics of non-neoplastic mediastinal cysts are examined with discussion of the role of immunohistochemistry and the most pertinent differential diagnosis.
The Magnitude and Duration of the Effect of Intra-articular Corticosteroid Injections on Pain Severity in Knee Osteoarthritis
Authors: Saltychev Mikhail , Mattie Ryan , McCormick Zachary , Laimi Katri
Published: January 2020

Objectives

The aims of the study were to clarify the evidence on the magnitude and duration of treatment effect of intra-articular corticosteroid injections for knee osteoarthritis compared with placebo, to evaluate a treatment effect by steroid type, and to describe the reported adverse effects.

Design

Cochrane Controlled Trials Register, Medline, Embase, CINAHL, Scopus, and Web of Science databases were searched. The risk of systematic bias was assessed according to the Cochrane Collaboration’s domain-based evaluation framework.

Results

The final sample included eight randomized controlled studies with follow-ups from 1 to 26 wks. The risk of systematic bias was considered low in five and high in three studies. The pooled standardized mean difference was −0.58 (95% confidence interval = −0.88 to −0.27) and number needed to treat 5.1 (95% confidence interval = 10.0 to 3.7). The heterogeneity was considerable. The pooled effect size approached the level of statistical insignificance at 4 mos. The pooled risk ratio of adverse effects was insignificant 0.95 (95% confidence interval = 0.34 to 2.55).

Conclusions

The intra-articular corticosteroid had a mild to moderate effect on pain severity up to 3 mos after the injection—much longer than it had previously been reported. The effect may vary substantially in different patient groups and appropriate patient selection is important. The risk of adverse effects was low.
Predictors of Exceeding Target Inpatient Rehabilitation Length of Stay After Hip Fracture
Authors: Daly Natalie , Fortin Christian , Jaglal Susan , MacDonald Shannon L.
Published: January 2020

Objective

The aim of the study was to identify factors associated with exceeding a target inpatient rehabilitation length of stay of 28 days or less for individuals with hip fracture.

Design

Retrospective cohort study of hip fracture patients admitted to an urban Canadian inpatient rehabilitation facility between January 1, 2013, and January 1, 2018. Patient characteristics previously shown to be associated with individual outcomes and/or length of stay after hip fracture were extracted from the institution’s data warehouse. Regression models were used to examine factors associated with exceeding target length of stay as well as overall length of stay.

Results

Four hundred ninety-three subjects were included in the analysis. Three hundred forty-five (70%) met and 148 (30%) exceeded their target length of stay. Patients who exceeded their target were more likely to be elderly (odds ratio, 1.05; 95% confidence interval, 1.02–1.08), to live alone prefracture (odds ratio, 1.72; 95% confidence interval, 1.02–2.91), to have dementia (odds ratio, 2.79; 95% confidence interval, 1.12–6.97), and higher admission pain scores (severe pain odds ratio, 2.51; 95% confidence interval, 1.06–5.93). Higher admission motor Functional Independence Measure scores (odds ratio, 0.95; 95% confidence interval, 0.92–0.98) were protective.

Conclusions

Advancing age, having dementia, living alone prefracture, and reporting moderate or severe pain at the time of admission not only increased the odds of an individual exceeding their target length of stay but also was associated with an overall increase in length of stay. Conversely, having a higher admission motor Functional Independence Measure score was protective.
Burden and Patterns of Multimorbidity
Authors: Jacob Mini E. , Ni Pengsheng , Driver Jane , Leritz Elizabeth , Leveille Suzanne G. , Jette Alan M. , Bean Jonathan F.
Published: January 2020

Objective

The aim of this study was to assess the impact of the burden and patterns of multimorbidity on disability domains.

Design

In a cross-sectional study of 425 older adults from the Boston Rehabilitative Impairment Study of the Elderly, participants self-reported 13 chronic conditions and underwent assessment of body function (leg strength, velocity, and power, trunk extensor endurance, leg range of motion, foot sensation), activities (400-m walk test, Short Physical Performance Battery, Late Life Function and Disability Instrument function scores) and participation (Late Life Function and Disability Instrument participation scores). The association between multimorbidity patterns (identified by latent class analysis) and disablement measures, as well as multimorbidity burden (captured by a multimorbidity score) and disablement measures, was tested.

Results

Latent class analysis identified three classes—low multimorbidity, high multimorbidity, and predominantly musculoskeletal conditions. Class membership (multimorbidity pattern) was not associated with disablement measures, but multimorbidity score was associated with poor performance in all domains. A 1-point higher multimorbidity score was associated with lower scores in body functions (by 0.06 SD unit), activities (0.07–0.10 SD units), as well as participation (0.07–0.09 units).

Conclusion

Multimorbidity counts may be an excellent tool for risk stratification and identification of persons in need of rehabilitation.

To Claim CME Credits

Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME

CME Objectives

Upon completion of this article, the reader should be able to (1) describe and distinguish the effect of multimorbidity burden and multimorbidity patterns on three disability domains in older adults; (2) identify and discuss possible reasons why high multimorbidity burden may result in a restriction among social participation in older adults; and (3) detect disability risk among older patients during clinical assessment by using a simple count of common chronic conditions.

Level

Advanced

Accreditation

The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.
Effectiveness of Ultrasound-Guided Platelet-Rich Plasma Injections in Relieving Sacroiliac Joint Dysfunction
Authors: Wallace Patrick , Bezjian Wallace Laurie , Tamura Sarah , Prochnio Kirk , Morgan Kyle , Hemler Douglas
Published: January 2020

Objective

The aim of the study was to investigate the efficacy of ultrasound-guided platelet-rich plasma in reducing sacroiliac joint disability and pain.

Design

Prospective nonrandomized interventional study analyzing 50 patients with low back pain secondary to sacroiliac joint dysfunction. Platelet-rich plasma was injected into the sacroiliac joint under ultrasound guidance. Oswestry Disability Index and Numeric Rating Scale were measured at baseline, 2 wks, 4 wks, 3 mos, and 6 mos after injection.

Results

The mean reduction in Oswestry Disability Index and Numeric Rating Scale scores were significantly reduced at 6 mos after injection compared with baseline values (mean = −9.79%, 95% CI = −6.06 to −13.52) and (mean = −1.94, 95% CI = −1.14 to −2.78), respectively. All timeframes showed significant mean reduction compared with baseline, but overall improvement tapers off after 4 wks with no statistically significant reduction from 4 wks to 3 mos or 3 to 6 mos.

Conclusions

Ultrasound-guided platelet-rich plasma injections in the sacroiliac joint are effective at reducing disability and pain with most improvement seen within 4 wks after injection and with sustained reduction at 6 mos.
Depot medroxyprogesterone acetate administration increases cervical CCR5+CD4+ T cells and induces immunosuppressive milieu at the cervicovaginal mucosa
Authors: Tasker Carley , Pizutelli Vanessa , Lo Yungtai , Ramratnam Bharat , Roche Natalie E. , Chang Theresa L.
Published: January 2020

Objectives:

Depot medroxyprogesterone acetate (Depo-Provera) is the most commonly used injectable hormone contraceptive in Sub-Saharan Africa where HIV incidence is high. We determined the impact of Depo-Provera on cervical immune cells and mediators in healthy women.

Methods:

In this longitudinal study, vaginal, endocervical, and rectal swabs were collected at baseline (visit 1), 1 month (visit 2), and 3 months (visit 3) after Depo-Provera injection. Cervical cells were collected by cytobrush and immune markers on cervical CD4+ T cells were analyzed by multicolor flow cytometry at three different visits. The levels of immune mediators in cytobrush supernatants as well as vaginal, cervical, and rectal secretions from swabs were analyzed by multiplex assays and ELISA.

Results:

Compared with baseline levels, we found a significant increase in the frequency of cervical CCR5+CD4+ T cells and a significant decrease in the frequency of cervical central memory CD4+ T cells. Depo-Provera treatment had little effect on expression of immune mediators in rectal mucosa but significantly suppressed numerous immune mediators at cervicovaginal mucosa. Levels of MCP-1, G-CSF, IL-6, IL-10, GM-CSF, and IP-10 were significantly decreased in both vaginal and cervical secretions after Depo-Provera injection. In cervical samples collected by cytobrush, we found reduced levels of 22 of 25 immune mediators after Depo-Provera injection. Changes in immune mediators differed between vaginal and cervical mucosa, demonstrating compartment-specific responses.

Conclusion:

Depo-Provera altered immune profiles of cervical CD4+ T cells and suppressed host immune response at cervicovaginal mucosa, suggesting its likely effect on transmission of sexually transmitted infections including HIV.
Plasma and antibody glycomic biomarkers of time to HIV rebound and viral setpoint
Authors: Giron Leila B. , Papasavvas Emmanouil , Azzoni Livio , Yin Xiangfan , Anzurez Alitzel , Damra Mohammad , Mounzer Karam , Kostman Jay R. , Sanne Ian , Firnhaber Cynthia S. , Tateno Hiroaki , Liu Qin , Montaner Luis J. , Abdel-Mohsen Mohamed
Published: January 2020

Objective:

HIV cure research urgently needs to identify pre-analytic treatment interruption (ATI) biomarkers of time-to-viral-rebound and viral setpoint to mitigate the risk of ATI and accelerate development of a cure. We previously reported that galactosylated IgG glycans, G2, negatively correlate with cell-associated HIV DNA and RNA during antiretroviral therapy (ART). We hypothesized that this and other plasma glycomic traits can predict time-to-viral-rebound and viral setpoint upon ART cessation.

Design:

We profiled the circulating glycomes (plasma and bulk IgG) of two geographically distinct cohorts: Philadelphia Cohort – 24 HIV-infected, ART-suppressed individuals who had participated in an open-ended ATI study without concurrent immunomodulatory agents. Johannesburg Cohort – 23 HIV-infected, ART-suppressed individuals who had participated in a 2-week ATI.

Methods:

Capillary electrophoresis and lectin microarray were used for glycomic analyses. Cox proportional-hazards model and log-rank test were used for statistical analyses.

Results:

Higher pre-ATI levels of the IgG glycan, G2, were significantly associated with a longer time-to-viral-rebound (hazard ratio = 0.12, P = 0.05). In addition to G2, we identified several predictive glycomic traits in plasma, for example, levels of FA2BG1, a non-sialylated, core-fucosylated glycan, associated with a longer time-to-viral-rebound (hazard ratio = 0.023, P = 0.05), whereas FA2G2S1, a sialylated glycan, associated with a shorter time-to-viral-rebound (hazard ratio = 24.1, P = 0.028). Additionally, pre-ATI plasma glycomic signatures associated with a lower viral setpoint, for example, T-antigen (Galβ1-3GalNAc) (r = 0.75, P = 0.0007), or a higher viral setpoint, for example, polylactosamine (r = −0.58, P = 0.01). These results were initially validated in the Johannesburg Cohort.

Conclusion:

We describe first-in-class, non-invasive, plasma and IgG glycomic biomarkers that inform time-to-viral-rebound and viral setpoint in two geographically distinct cohorts.
Tetramethylpyrazine/Ligustrazine Can Improve the Survival Rate of Adipose-Derived Stem Cell Transplantation
Authors: Zhou Jinghe , Zhang Jufang , Wu Lihong , Zhu Fei , Xu Huifang
Published: January 2020

Background

We aimed to study the effect of tetramethylpyrazine/ligustrazine (TMP) on the survival rate of adipose-derived stem cell (ADSC) transplantation.

Methods

Human ADSCs were cultured and subcultured. Detection of cell growth was performed using CCK8 kit. A total of 12 BALB/c nude mice including 4 groups (group 1: ADSC–hyaluronic acid [HA] + phosphate-buffered saline [PBS]; group 2: ADSC-HA + TMP injection; group 3: ADSC-HA + TMP soaking; group 4: ADSC-HA + TMP injection + TMP soaking) were used for the animal experiments. Furthermore, hematoxylin-eosin staining and oil red O staining were conducted for the frozen section from the animal tissues. Besides, RNA was extracted from the samples, and reverse transcriptase–polymerase chain reaction experiment was performed. At last, samples were detected using transmission electron microscope.

Results

Tetramethylpyrazine/ligustrazine resulted in significant increase for cell proliferation on the seventh day. It was easier to promote the growth of adipose cell after injection and soaking of TMP. Hematoxylin-eosin staining and oil red O stain showed that injection and soaking of TMP could significantly increase the size of fat. The relative expression of peroxisome proliferator–activated receptor γ, CCAAT/enhancer-binding protein α, and Alu in group 4 was significantly higher than that in other groups.

Conclusions

Tetramethylpyrazine/ligustrazine can improve the survival rate of ADSC transplantation. The possible mechanisms of it may be that TMP induces the expression of transcription factor associated with fat formation including peroxisome proliferator–activated receptor γ, CCAAT/enhancer-binding protein α, and Alu and then promotes the growth of adipose cell.
Composite Tissue Preservation
Authors: Dickey Ryan M. , Hembd Austin S. , Fruge Seth , Haddock Nicholas T. , Papas Klearchos K. , Suszynski Thomas M.
Published: January 2020

Composite tissue (CT) preservation is important to outcomes after replant or transplant. Since the first limb replant, the mainstay of preservation has been static cold storage with the amputated part being placed in moistened gauze over ice. Historically, the gold-standard in solid organ preservation has been static cold storage with specialized solution, but this has recently evolved in the last few decades to develop technologies such as machine perfusion and even persufflation. This review explores the impact of cooling and oxygenation on CT, summarizes the work done in the area of CT preservation, discusses lessons learned from our experience in solid organ preservation, and proposes future directions.
Utility of a Team-Based Multimodal Opioid Reduction Protocol for the Pediatric Plastic Surgery Population
Authors: Crowley Jiwon Sarah , Hsieh Sun , Gabriel Rodney A. , McLean Paige , Gosman Amanda , Lance Samuel
Published: January 2020

Opioid use can cause significant adverse side effects with increased propensity toward both short- and long-term complications in the pediatric population. We present a multifaceted opioid reduction protocol based on physician and care team member education. The strategy was designed to alter prescribing practices, improve preoperative and postoperative patient education, increase the use of nonnarcotic pain control modalities, and improve coordination of opiate reduction strategies for all team members participating in patient care. We present the utility of this strategy in limiting postoperative narcotic use in the pediatric plastic surgery population.

A prospective study with historical controls was conducted to evaluate pediatric patients undergoing elective pediatric plastic surgery procedures at 3-month intervals in 2016, 2017, and 2018. In the final year, the dedicated opiate reduction protocol was implemented before the data collection period, and results were compared with the prior 2 collection periods. The primary outcomes were total days and doses of outpatient narcotics prescribed after surgery.

The median days (quartiles) of opioids prescribed in 2016, 2017, and 2018 cohorts were 1.5 (1.1, 2.5) days, 1.5 (1.4, 2.5) days, and 0.8 (0, 1.6) days, respectively. The median doses (quartiles) of opioids prescribed in 2016, 2017, and 2018 cohorts were 6.3 (6, 10), 6.0 (5.7, 15.0), and 4.2 (0, 6.2) doses, respectively. There were statistically significantly less days and doses of opioids prescribed in the 2018 cohort when compared with the 2016 (P < 0.0001) and 2017 (P < 0.0001) cohorts.

A multimodal opioid reduction protocol was successfully implemented for the pediatric plastic surgery population. Patients were able to shorten the duration of narcotic prescription upon discharge with the use of a multidisciplinary team approach.
Diversity in Plastic Surgery
Authors: Reghunathan Meera , Parmeshwar Nisha , Gallus Katerina M. , Gosman Amanda A.
Published: January 2020

Background

Prior studies have shown that roadblocks exist for women to achieve higher career levels in plastic surgery. The authors evaluate female representation as lecturers, panelists, and moderators at national and regional plastic surgery meetings.

Methods

The annual meetings between January 2014 and January 2019 for 12 national and regional plastic surgery societies were included in this study. Data regarding sex of speakers were extracted from meeting programs. Binomial distribution analysis was used to compare female representation at meetings as compared with female representation among plastic surgeons. Analysis of variance with Tukey post hoc analysis was used to evaluate for differences in female representation among regions and subspecialties.

Results

Females comprised 14.8% of speakers, including instructors, moderators, and panelists, at all included plastic surgery meetings. There has not been a significant increase in the representation of females at plastic surgery meetings in the past 5 years (P = 0.08). Five of 12 societies had significantly lower female representation as speakers than expected by the proportion of female plastic surgeons (P < 0.05). American Society for Craniofacial Surgeons had significantly lower representation as compared with other subspecialty meetings (P < 0.01), and Texas Society of Plastic Surgeons had significantly lower representation among regional meetings (P < 0.05).

Conclusions

Female representation among plastic surgery residents and faculty has increased, yet women remain disproportionately underrepresented on the podium at educational meetings. Providing women the opportunity to serve as speakers, moderators, and panelists at meetings will ultimately enhance the diversity of our plastic surgical leadership.
Worse Than Death: Survey of Public Perceptions of Disability Outcomes After Hypothetical Traumatic Brain Injury
Authors: Wilson Jo Ellen , Shinall Myrick C. , Leath Taylor C. , Wang Li , Harrell Frank E. , Wilson Laura D. , Nordness Mina F. , Rakhit Shayan , de Riesthal Michael R. , Duff Melissa C. , Pandharipande Pratik P. , Patel Mayur B.
Published: January 2020

Objective:

The aim of this study was to determine the health utility states of the most commonly used traumatic brain injury (TBI) clinical trial endpoint, the Extended Glasgow Outcome Scale (GOSE).

Summary Background Data:

Health utilities represent the strength of one's preferences under conditions of uncertainty. There are insufficient data to indicate how an individual would value levels of disability after a TBI.

Methods:

This was a cross-sectional web-based online convenience sampling adaptive survey. Using a standard gamble approach, participants evaluated their preferences for GOSE health states 1 year after a hypothetical TBI. The categorical GOSE was studied from vegetative state (GOSE2) to upper good recovery (GOSE8). Median (25th percentile, 75th percentile) health utility values for different GOSE states after TBI, ranging from −1 (worse than death) to 1 (full health), with 0 as reference (death).

Results:

Of 3508 eligible participants, 3235 (92.22%) completed the survey. Participants rated lower GOSE states as having lower utility, with some states rated as worse than death, though the relationship was nonlinear and intervals were unequal between health states. Over 75% of participants rated a vegetative state (GOSE2, absence of awareness and bedridden) and about 50% rated lower severe disability (GOSE3, housebound needing all-day assistance) as conditions worse than death.

Conclusions:

In the largest investigation of public perceptions about post-TBI disability, we demonstrate unequally rated health states, with some states perceived as worse than death. Although limited by selection bias, these results may guide future comparative-effectiveness research and shared medical decision-making after neurologic injury.
How to Handle Arterial Conduits in Liver Transplantation? Evidence From the First Multicenter Risk Analysis
Authors: Oberkofler Christian E. , Raptis Dimitri A. , DiNorcia Joseph , Kaldas Fady M. , Müller Philip C. , Pita Alejandro , Genyk Yuri , Schlegel Andrea , Muiesan Paolo , Tun Abraham Mauro E. , Dokus Katherine , Hernandez-Alejandro Roberto , Rayar Michel , Boudjema Karim , Mohkam Kayvan , Lesurtel Mickaël , Esser Hannah , Maglione Manuel , Vijayanand Dhakshina , Lodge J. Peter A. , Owen Timothy , Malagó Massimo , Mittler Jens , Lang Hauke , Khajeh Elias , Mehrabi Arianeb , Ravaioli Matteo , Pinna Antonio D. , Dutkowski Philipp , Clavien Pierre-Alain , Busuttil Ronald W. , Petrowsky Henrik
Published: January 2020

Objective:

The aims of the present study were to identify independent risk factors for conduit occlusion, compare outcomes of different AC placement sites, and investigate whether postoperative platelet antiaggregation is protective.

Background:

Arterial conduits (AC) in liver transplantation (LT) offer an effective rescue option when regular arterial graft revascularization is not feasible. However, the role of the conduit placement site and postoperative antiaggregation is insufficiently answered in the literature.

Study Design:

This is an international, multicenter cohort study of adult deceased donor LT requiring AC. The study included 14 LT centers and covered the period from January 2007 to December 2016. Primary endpoint was arterial occlusion/patency. Secondary endpoints included intra- and perioperative outcomes and graft and patient survival.

Results:

The cohort was composed of 565 LT. Infrarenal aortic placement was performed in 77% of ACs whereas supraceliac placement in 20%. Early occlusion (≤30 days) occurred in 8% of cases. Primary patency was equivalent for supraceliac, infrarenal, and iliac conduits. Multivariate analysis identified donor age >40 years, coronary artery bypass, and no aspirin after LT as independent risk factors for early occlusion. Postoperative antiaggregation regimen differed among centers and was given in 49% of cases. Graft survival was significantly superior for patients receiving aggregation inhibitors after LT.

Conclusion:

When AC is required for rescue graft revascularization, the conduit placement site seems to be negligible and should follow the surgeon's preference. In this high-risk group, the study supports the concept of postoperative antiaggregation in LT requiring AC.
Treatment for Infected Pancreatic Necrosis Should be Delayed, Possibly Avoiding an Open Surgical Approach
Authors: Ricci Claudio , Pagano Nico , Ingaldi Carlo , Frazzoni Leonardo , Migliori Marina , Alberici Laura , Minni Francesco , Casadei Riccardo
Published: January 2020

Objective:

To evaluate all invasive treatments for suspected IPN.

Summary of Background Data:

The optimal invasive treatment for suspected IPN remains unclear.

Methods:

A systematic search of randomized clinical trials comparing at least 2 invasive strategies for the treatment of suspected IPN was carried out. A frequentist random-effects network meta-analysis was made reporting the surface under the cumulative ranking (SUCRA). The primary endpoint regarded both the in-hospital mortality and major morbidity rates. The secondary endpoints were mortality, length of stay, intensive care unit stay, the pancreatic fistula rate, and exocrine and endocrine insufficiency.

Results:

Seven studies were included, involving 400 patients clustered as following: 64 (16%) in early surgical debridement (ED); 27 (6.7%) in peritoneal lavage (PL); 45 (11.3%) in delayed surgical debridement (DD), 169 (42.3%) in the step-up approach with minimally invasive debridement (SUA-DD) and 95 (23.7%) with endoscopic debridement (SUA-EnD). The step-up approach with endoscopic debridement had the highest probability of being the safest approach (SUCRA 87.1%), followed by SUA-DD (SUCRA 59.5%); DD, ED, and PL had the lowest probability of being safe (SUCRA values 27.6%, 31.4%, and 44.4%, respectively). Analysis of the secondary endpoints confirmed the superiority of SUA-EnD regarding length of stay, intensive care unit stay, pancreatic fistula rate, and new-onset diabetes. The SUA approaches are similar regarding exocrine function. Mortality was reduced by any delayed approaches (DD, SUA-DD, or SUA-EnD).

Conclusions:

The first choice for suspected IPN seemed to be SUA-EnD. An alternative could be SUA-DD. PL, ED, and DD should be avoided.
Early Identification of Trauma-induced Coagulopathy
Authors: Perkins Zane B. , Yet Barbaros , Marsden Max , Glasgow Simon , Marsh William , Davenport Ross , Brohi Karim , Tai Nigel R. M.
Published: January 2020

Objective:

The aim of this study was to develop and validate a risk prediction tool for trauma-induced coagulopathy (TIC), to support early therapeutic decision-making.

Background:

TIC exacerbates hemorrhage and is associated with higher morbidity and mortality. Early and aggressive treatment of TIC improves outcome. However, injured patients that develop TIC can be difficult to identify, which may compromise effective treatment.

Methods:

A Bayesian Network (BN) prediction model was developed using domain knowledge of the causal mechanisms of TIC, and trained using data from 600 patients recruited into the Activation of Coagulation and Inflammation in Trauma (ACIT) study. Performance (discrimination, calibration, and accuracy) was tested using 10-fold cross-validation and externally validated on data from new patients recruited at 3 trauma centers.

Results:

Rates of TIC in the derivation and validation cohorts were 11.8% and 11.0%, respectively. Patients who developed TIC were significantly more likely to die (54.0% vs 5.5%, P < 0.0001), require a massive blood transfusion (43.5% vs 1.1%, P < 0.0001), or require damage control surgery (55.8% vs 3.4%, P < 0.0001), than those with normal coagulation. In the development dataset, the 14-predictor BN accurately predicted this high-risk patient group: area under the receiver operating characteristic curve (AUROC) 0.93, calibration slope (CS) 0.96, brier score (BS) 0.06, and brier skill score (BSS) 0.40. The model maintained excellent performance in the validation population: AUROC 0.95, CS 1.22, BS 0.05, and BSS 0.46.

Conclusions:

A BN (http://www.traumamodels.com) can accurately predict the risk of TIC in an individual patient from standard admission clinical variables. This information may support early, accurate, and efficient activation of hemostatic resuscitation protocols.
The Effect of Postoperative Complications After Minimally Invasive Esophagectomy on Long-term Survival
Authors: Fransen Laura F. C. , Berkelmans Gijs H. K. , Asti Emanuele , van Berge Henegouwen Mark I. , Berlth Felix , Bonavina Luigi , Brown Andrew , Bruns Christiane , van Daele Elke , Gisbertz Suzanne S. , Grimminger Peter P. , Gutschow Christian A. , Hannink Gerjon , Hölscher Arnulf H. , Kauppi Juha , Lagarde Sjoerd M. , Mercer Stuart , Moons Johnny , Nafteux Philippe , Nilsson Magnus , Palazzo Francesco , Pattyn Piet , Raptis Dimitri A. , Räsanen Jari , Rosato Ernest L. , Rouvelas Ioannis , Schmidt Henner M. , Schneider Paul M. , Schröder Wolfgang , van der Sluis Pieter C. , Wijnhoven Bas P. L. , Nieuwenhuijzen Grard A. P. , Luyer Misha D. P.
Published: January 2020

Background:

Esophagectomy is a technically challenging procedure, associated with significant morbidity. The introduction of minimally invasive esophagectomy (MIE) has reduced postoperative morbidity.

Objective:

Although the short-term effect on complications is increasingly being recognized, the impact on long-term survival remains unclear. This study aims to investigate the association between postoperative complications following MIE and long-term survival.

Methods:

Data were collected from the EsoBenchmark Collaborative composed by 13 high-volume, expert centers routinely performing MIE. Patients operated between June 1, 2011 and May 31, 2016 were included. Complications were graded using the Clavien-Dindo (CD) classification. To correct for short-term effects of postoperative complications on mortality, patients who died within 90 days postoperative were excluded. Primary endpoint was 5-year overall survival.

Results:

A total of 915 patients were included with a mean follow-up time of 30.8 months (standard deviation 17.9). Complications occurred in 542 patients (59.2%) of which 50.2% had a CD grade ≥III complication [ie, (re)intervention, organ dysfunction, or death]. The incidence of anastomotic leakage (AL) was 135 of 915 patients (14.8%) of which 84 patients were classified as a CD grade ≥III. Multivariable analysis showed a significantly deteriorated long-term survival in all patients with AL [hazard ratio (HR) 1.68, 95% confidence interval (CI) 1.25–2.24]. This inverse relation was most distinct when AL was scored as a CD grade ≥III (HR 1.83, 95% CI 1.30–2.58). For all other complications, no significant association with long-term survival was found.

Conclusion:

The occurrence and severity of AL, but not overall complications, after MIE negatively affect long-term survival of esophageal cancer patients.
Quality of Life After Caustic Ingestion
Authors: Faron Matthieu , Corte Helene , Poghosyan Tigran , Bruzzi Matthieu , Voron Thibault , Sarfati Emile , Cattan Pierre , Chirica Mircea
Published: January 2020

Objective:

The aim of the study was to evaluate long-term QOL after caustic ingestion.

Background:

Caustic ingestion strongly affects patient's QOL but data on the topic is scarce in the literature.

Methods:

QOL evaluation was conducted in survivors from a large cohort of patients with caustic injuries. QOL was assessed using the EORTC QLQ-OG25 module, the SF12v2 score, and the hospital anxiety and depression scale questionnaire. One hundred thirty-four patients (59 men, median age 43) completed the survey; 72 (54%) patients underwent emergency digestive resection and in 99 (74%) patients underwent esophageal reconstruction. Results of QOL questionnaires were compared to average values determined in healthy volunteers and in patients with esophageal cancers.

Results:

The median QLQ-OG25 score was 44 (34, 62) and values were significantly lower when compared to a normal population (P < 0.0001). SF12v2 scores were significantly inferior to those expected in a normal population on both the physical component summary (PCS) (43.3 ± 10.8; P < 0.0001) and the mental component summary (44 ± 9.7; P < 0.0001) scales. Emergency esophageal resection was significantly associated with higher QLQ-OG25 scores (P < 0.0001), but not with mental component summary (P = 0.3), PCS (P = 0.76), HAD anxiety (P = 0.95), and HAD depression scores (P = 0.59); results were similar after extended emergency resection. When compared to esophagocoloplasty alone, pharyngeal reconstruction had a significant negative impact on QLQ-OG25 (P < 0.0001), PCS (P = 0.01), and HAD depression (P = 0.0008) scores.

Conclusions:

QOL is significantly impaired after caustic ingestion. QOL issues should not influence the emergency surgical strategy but deserve discussion before esophageal reconstruction for caustic injuries.
Use and Misuse of Opioids After Endocrine Surgery Operations
Authors: Kuo Jennifer H. , Huang Yongmei , Kluger Michael D. , Hershman Dawn L. , Chabot John A. , Lee James A. , Wright Jason D.
Published: January 2020

Objective:

To examine the rate of new and persistent opioid use after endocrine surgery operations

Summary of Background Data:

A global epidemic of opioid misuse and abuse has been evolving over the past 2 decades with opioid use among surgical patients being a particularly difficult problem. Minimal data exists regarding opioid misuse after endocrine surgical operations.

Methods:

A retrospective cohort study using the MarketScan identified adult patients who underwent thyroidectomy, parathyroidectomy, neck dissections for thyroid malignancy, and adrenalectomy from 2008 to 2017. Persistent opioid use was defined as receipt of ≥1 opioid prescription 90–180 days postop with no intervening procedures or anesthesia. Multivariable models were used to examine associations between clinical characteristics and any use and new persistent use of opioids.

Results:

A total of 259,115 patients were identified; 54.6% of opioid naïve patients received a perioperative opioid prescription. Fulfillment of this prescription was associated with malignant disease, greater extent of surgery, younger age, residence outside of the Northeast, and history of depression or substance abuse. The rate of new persistent opioid use was 7.4%. A lateral neck dissection conferred the highest risk for persistent opioid use (P < 0.01). Persistent opioid use was also associated with older age, Medicaid coverage, residency outside of the Northeast, increased medical co-morbidities, a history of depression, anxiety, substance use disorder, and chronic pain (all P < 0.01). Importantly, the risk for persistent opioid use increased with higher doses of total amount of opioids prescribed.

Conclusions:

The rate of new, persistent opioid use after endocrine surgery operations is substantial but may be mitigated by decreasing the number of postoperative opioids prescribed.
Subclassification of Microscopic Vascular Invasion in Hepatocellular Carcinoma
Authors: Kang Incheon , Jang Mi , Lee Jae Geun , Han Dai Hoon , Joo Dong Jin , Kim Kyung Sik , Kim Myoung Soo , Choi Jin Sub , Kim Soon Il , Park Young Nyun , Choi Gi Hong
Published: January 2020

Objective:

To investigate whether subclassification of microscopic vascular invasion (MiVI) affects the long-term outcome after curative surgical resection or liver transplantation (LT) in patients with hepatocellular carcinoma (HCC).

Summary of Background Data:

The most important factor for TNM staging in HCC is MiVI, which includes all vascular invasions detected on microscopic examination. However, there is a broad spectrum of current definitions for MiVI.

Methods:

In total, 412 consecutive patients with HCC who underwent curative surgical resection without any preoperative treatment or gross vascular invasion were histologically evaluated for MiVI. Patients with MiVI were subclassified into 2 groups: microvessel invasion (MI; n = 164) only and microscopic portal vein invasion (MPVI; n = 36). Clinicopathologic features were compared between 2 groups (MI vs MPVI), whereas disease-free survival (DFS) and overall survival (OS) after resection were analyzed among 3 groups (no vascular invasion [NVI] vs MI vs MPVI). These subclassifications were validated in a cohort of 197 patients with HCC who underwent LT.

Results:

The MPVI group showed more aggressive tumor characteristics, such as higher tumor marker levels (alpha-fetoprotein, P = 0.006; protein induced by vitamin K absence-II, P = 0.001) and poorer differentiation (P = 0.011), than the MI group. In multivariate analysis, both MI and MPVI were independent prognostic factors for DFS (P = 0.001 and <0.001, respectively) and OS (P = 0.005 and <0.001, respectively). In the validation cohort, 5-year DFS was 89%, 67.9%, and 0% in the NVI, MI, and MPVI groups, respectively (P < 0.001), whereas 5-year OS was 79.1%, 55.0%, and 15.4%, respectively (P < 0.001).

Conclusions:

Based on subclassification of MiVI in HCC, MPVI was associated with more aggressive clinicopathologic characteristics and poorer survival than MI only. Therefore, the original MiVI classification should be divided into MI and MPVI.
Pancreatic Stone Protein Predicts Sepsis in Severely Burned Patients Irrespective of Trauma Severity
Authors: Klein Holger Jan , Niggemann Pia , Buehler Philipp Karl , Lehner Fabienne , Schweizer Riccardo , Rittirsch Daniel , Fuchs Nina , Waldner Matthias , Steiger Peter , Giovanoli Pietro , Reding Theresia , Graf Rolf , Plock Jan Alexander
Published: January 2020

Objective:

The burn victim's inherent state of hyperinflammation frequently camouflages septic events delaying the initiation of targeted intensive care therapy. Accurate biomarkers are urgently needed to support sepsis detection before patients’ clinical deterioration.

Summary of Background Data:

Evidence on the usefulness of pancreatic stone protein (PSP) as a powerful diagnostic and prognostic marker in critically ill patients has recently accumulated.

Methods:

Analysis of biomarker kinetics (PSP, routine markers) was performed on 90 patients admitted to the Zurich Burn Center between May 2015 and October 2018 with burns ≥15% total body surface area with regard to infection and sepsis (Sepsis-3) over a 14-day time course.

Results:

PSP differentiated between sepsis, infection and sterile inflammation from day 3 onward with an area under the curve of up to 0.89 (P < 0.001), therefore, competing with procalcitonin (area under the curve = 0.86, P < 0.001). Compared to routine inflammatory biomarkers, only PSP demonstrated a significant interaction between time and presence of sepsis – signifying a steeper increase in PSP levels in septic patients as opposed to those exhibiting a nonseptic course (interaction P < 0.001). Event-related analysis demonstrated tripled PSP serum levels within 72 hours and doubled levels within 48 hours before a clinically apparent sepsis.

Conclusion:

PSP is able to differentiate between septic and nonseptic patients during acute burn care. Its steep rise up to 72 hours before clinically overt deterioration has the potential for physicians to timely initiate treatment with reduced mortality and costs.